OVER A COFFEE: The doctor’s dilemma —Dr Haider Shah
With a good risk management system in place, the occurrence of untoward incidents can be minimised but not completely rooted out. Problems will still creep in through the slightest crevices in the system
Life is precious and its loss is always deplorable. Nothing can, however, be more tragic when a life-saving medicine becomes a messenger of death for more than 100 poor patients. Though political opportunists have quickly seized on the incident to make some political capital out of a multi-faceted issue of public policy, the sad incident is more a wakeup call for reinvigorating our inept healthcare management. The situation is an interplay of many dilemmas and reminds me of Bernard Shaw’s play, The Doctor’s Dilemma, which was later screened as a movie in 1958.
The main theme of the play is about the dilemma a doctor faces in using his scarce cure for tuberculosis by deciding whether to use it for a poor colleague or for a talented artist with questionable morals. Shaw also highlights another dilemma faced by the then doctors who wanted to get rich by grappling with the temptation of carrying out expensive but useless treatments of patients. The play popularised the need for greater involvement of the state in providing healthcare services and hence paved the way for the National Health Services (NHS) in the UK. Doctors paid well by the state were therefore saved from the general dilemma of choosing between personal prosperity and patients’ welfare. Today the NHS is the second biggest constituent (i.e. 17 percent after pensions, which is 18 percent) of total public spending in the UK.
Three important lessons can be learned from the large scale deaths caused by contaminated medicine, Isotab. One, it has exposed a complete absence of any regulatory mechanism for the medicines market. In fact, the incident is just the tip of the iceberg as the whole health sector is in a mess. For decades powerful predators have been feasting on the miseries of powerless patients — from corporate-minded doctors to pharmaceutical profiteers. There are thousands of unregulated pharmacies all over the country where you can get any kind of medicine without any prescription. A patient is never sure if the medicines purchased are genuine or fake. Thousands die every year due to this massive disregard for proper healthcare. But the calamity of the heinous situation had so far remained hidden because we have a complacent national attitude, which sweeps every criminal negligence or incompetence under the carpet of ‘it was God’s will’. For the first time we have discovered the temporal causes and in the process saw that the whole healthcare system was rotting.
Two, such is the state of our technical development that our laboratories were unable to detect heavy contamination of the medicine. Of what use are our nuclear installations and luminaries like Dr A Q Khan and Dr Mubarakmand if we cannot set up labs that, like the London and Swiss labs, can determine purity of life-saving medicines? What can a health minister or a chief executive of a hospital do if the technical system for ensuring the purity of drugs is non-existent?
Three, our public sector has still not embraced risk management and internal controls as the cornerstone of an efficient and accountable management. A stitch in time saves nine but we are in the habit of digging wells when the building is on fire. Management by walking around (MWA) is a good way of exercising control but it should supplement and not replace an effective system of Standard Operating Procedures (SOPs). Executives, at the provincial or organisational level, must put in place a sound risk management system. Back in the 1950s in the UK, Thalidomide was prescribed to relieve morning sickness in the first few months of pregnancy, which later caused unpredicted serious birth defects. The resulting outcry kick-started medicines regulation in the UK. In Pakistan, we still are waiting for one in 2012. No doubt the government has shown criminal negligence by not setting up a Drug Regulatory Authority and instead remained embroiled in a dispute over the ownership of a Lahore-based hospital with the provincial government after the promulgation of the 18th Amendment. But our media should also share part of the blame as it spends all its energy on bringing the heavens down on Memogate kind of mumbo jumbo.
There is another worrying aspect of our health sector as well. The doctors’ associations behave not much differently from organised mafias; just the way all other professional bodies in Pakistan conduct themselves. Here in the UK, the British Medical Association acts as a watchdog over the conduct of doctors and does not take leniently any complaint of professional misconduct of registered doctors. Many doctors have lost their licences after disciplinary action by the association. How many doctors have lost licences due to action by the doctors’ association in Pakistan? This is not unique to doctors though. Recently, the lawyers’ association came to the rescue of a lawyer who had been charged with murdering his servant. Our doctors also quickly congregate to protect their comrades though they never take any action against the delinquent professionals in their ranks.
With a good risk management system in place, the occurrence of untoward incidents can be minimised but not completely rooted out. Problems will still creep in through the slightest crevices in the system. For instance, just recently in Belfast, Northern Ireland, three babies died in the neonatal unit of the city’s Royal Maternity Hospital after the outbreak of an infection. Twenty-three more babies are feared to have the same infection, as their parents are awaiting the results of tests. However, the health standards have quickly come in force to prevent any further havoc. Instead of a war of words for responsibility between the politicians, the focus is more on learning from an incident and putting good standards-based reaction systems in place.
The doctor’s dilemma is part of our national dilemma. The UK spends 17 percent on health (16 percent on social welfare and 13 percent on education) and seven percent on defence. In Pakistan, our priorities are altogether upside down, as we spend 30 percent of the budget on defence. How do we change from being a security state to a welfare state is a dilemma that we need to resolve soon. Health and progress are concomitant and we need better healthcare if we want to progress as a nation.
The writer teaches public policy in the UK and is the founding member of Rationalist Society of Pakistan. He can be reached at firstname.lastname@example.org